NUR 114 Exam 3 – Nursing Fundamentals
2026 NCLEX-Style Questions Answers &
Rationales
1. A nurse is caring for a client who has a new diagnosis of diabetes mellitus.
Which statement by the client indicates understanding of hyperglycemia
symptoms?
A. "I will watch for sweating and shakiness."
B. "I will watch for increased thirst and frequent urination."
C. "I will watch for weight gain and constipation."
D. "I will watch for blurred vision and headache only."
Answer: B
Rationale: Hyperglycemia symptoms include polyuria, polydipsia,
polyphagia. Sweating/shakiness are hypoglycemia symptoms.
2. A nurse is assessing a client's wound on post-operative day 3. Which
finding indicates a wound infection?
A. Serosanguineous drainage
B. Edges well approximated
C. Greenish drainage with foul odor
D. Mild tenderness to palpation
Answer: C
Rationale: Greenish, foul-smelling drainage indicates purulent drainage from
infection.
3. A client with heart failure is prescribed a 2-gram sodium diet. Which
breakfast choice is most appropriate?
A. Bacon and eggs with toast
,B. Oatmeal with fresh blueberries and unsalted butter
C. Canned soup with crackers
D. Ham and cheese omelet
Answer: B
Rationale: Oatmeal with fresh fruit and unsalted butter is low in sodium.
Bacon, ham, canned soup are high in sodium.
4. A nurse is caring for a client with an indwelling urinary catheter. Which
action is most important to prevent catheter-associated urinary tract
infection (CAUTI)?
A. Empty the drainage bag every 4 hours
B. Keep the drainage bag above the level of the bladder
C. Ensure the drainage bag is below the level of the bladder
D. Change the catheter every 24 hours
Answer: C
Rationale: Keeping the drainage bag below bladder level prevents backflow
of urine. Routine catheter changes are not recommended.
5. A client with a history of falls is taking furosemide. Which laboratory
value should the nurse monitor closely?
A. Hemoglobin
B. Potassium
C. Platelets
D. Calcium
Answer: B
Rationale: Furosemide (loop diuretic) causes potassium wasting →
hypokalemia risk.
,6. A nurse is teaching a client with a new colostomy about pouch care. How
often should the pouch be changed?
A. Every day
B. Every 3–7 days or when leaking
C. Every 12 hours
D. Twice per week only
Answer: B
Rationale: Pouches can last 3–7 days if the seal is intact. Frequent changes
cause skin breakdown.
7. A client with a new tracheostomy has a pulse oximetry of 84% on room
air. What should the nurse do first?
A. Suction the tracheostomy
B. Apply oxygen at 2 L/min
C. Call a rapid response
D. Change the inner cannula
Answer: A
Rationale: Low SpO2 with a new tracheostomy is often due to a mucus plug.
Suction first.
8. A nurse is assessing a client's cranial nerve III (oculomotor). Which
finding is abnormal?
A. Pupils constrict to light
B. Pupils are equal
C. One pupil is dilated and fixed
D. Pupils reactive
Answer: C
Rationale: Fixed, dilated pupil indicates CN III palsy or brain herniation – an
emergency.
, 9. A client with diabetes has a blood glucose of 50 mg/dL and is awake. What
should the nurse give first?
A. 4 oz of orange juice
B. Glucagon 1 mg IM
C. 50% dextrose IV push
D. A peanut butter sandwich
Answer: A
Rationale: Conscious client with hypoglycemia gets 15 g of fast-acting oral
carbohydrate (4 oz juice).
10. A nurse is caring for a client with a chest tube. The water seal chamber
has continuous bubbling. What should the nurse do?
A. Document as normal
B. Check for an air leak
C. Clamp the chest tube immediately
D. Increase suction pressure
Answer: B
Rationale: Continuous bubbling indicates an air leak. Clamping can cause
tension pneumothorax.
11. A client with heart failure reports a weight gain of 4 pounds in 2 days. The
nurse should:
A. Restrict fluids to 500 mL/day
B. Notify the provider (fluid retention)
C. Encourage a high-sodium diet
D. Document as expected finding
Answer: B
Rationale: Rapid weight gain (>2–3 lb/day) indicates worsening heart failure.
2026 NCLEX-Style Questions Answers &
Rationales
1. A nurse is caring for a client who has a new diagnosis of diabetes mellitus.
Which statement by the client indicates understanding of hyperglycemia
symptoms?
A. "I will watch for sweating and shakiness."
B. "I will watch for increased thirst and frequent urination."
C. "I will watch for weight gain and constipation."
D. "I will watch for blurred vision and headache only."
Answer: B
Rationale: Hyperglycemia symptoms include polyuria, polydipsia,
polyphagia. Sweating/shakiness are hypoglycemia symptoms.
2. A nurse is assessing a client's wound on post-operative day 3. Which
finding indicates a wound infection?
A. Serosanguineous drainage
B. Edges well approximated
C. Greenish drainage with foul odor
D. Mild tenderness to palpation
Answer: C
Rationale: Greenish, foul-smelling drainage indicates purulent drainage from
infection.
3. A client with heart failure is prescribed a 2-gram sodium diet. Which
breakfast choice is most appropriate?
A. Bacon and eggs with toast
,B. Oatmeal with fresh blueberries and unsalted butter
C. Canned soup with crackers
D. Ham and cheese omelet
Answer: B
Rationale: Oatmeal with fresh fruit and unsalted butter is low in sodium.
Bacon, ham, canned soup are high in sodium.
4. A nurse is caring for a client with an indwelling urinary catheter. Which
action is most important to prevent catheter-associated urinary tract
infection (CAUTI)?
A. Empty the drainage bag every 4 hours
B. Keep the drainage bag above the level of the bladder
C. Ensure the drainage bag is below the level of the bladder
D. Change the catheter every 24 hours
Answer: C
Rationale: Keeping the drainage bag below bladder level prevents backflow
of urine. Routine catheter changes are not recommended.
5. A client with a history of falls is taking furosemide. Which laboratory
value should the nurse monitor closely?
A. Hemoglobin
B. Potassium
C. Platelets
D. Calcium
Answer: B
Rationale: Furosemide (loop diuretic) causes potassium wasting →
hypokalemia risk.
,6. A nurse is teaching a client with a new colostomy about pouch care. How
often should the pouch be changed?
A. Every day
B. Every 3–7 days or when leaking
C. Every 12 hours
D. Twice per week only
Answer: B
Rationale: Pouches can last 3–7 days if the seal is intact. Frequent changes
cause skin breakdown.
7. A client with a new tracheostomy has a pulse oximetry of 84% on room
air. What should the nurse do first?
A. Suction the tracheostomy
B. Apply oxygen at 2 L/min
C. Call a rapid response
D. Change the inner cannula
Answer: A
Rationale: Low SpO2 with a new tracheostomy is often due to a mucus plug.
Suction first.
8. A nurse is assessing a client's cranial nerve III (oculomotor). Which
finding is abnormal?
A. Pupils constrict to light
B. Pupils are equal
C. One pupil is dilated and fixed
D. Pupils reactive
Answer: C
Rationale: Fixed, dilated pupil indicates CN III palsy or brain herniation – an
emergency.
, 9. A client with diabetes has a blood glucose of 50 mg/dL and is awake. What
should the nurse give first?
A. 4 oz of orange juice
B. Glucagon 1 mg IM
C. 50% dextrose IV push
D. A peanut butter sandwich
Answer: A
Rationale: Conscious client with hypoglycemia gets 15 g of fast-acting oral
carbohydrate (4 oz juice).
10. A nurse is caring for a client with a chest tube. The water seal chamber
has continuous bubbling. What should the nurse do?
A. Document as normal
B. Check for an air leak
C. Clamp the chest tube immediately
D. Increase suction pressure
Answer: B
Rationale: Continuous bubbling indicates an air leak. Clamping can cause
tension pneumothorax.
11. A client with heart failure reports a weight gain of 4 pounds in 2 days. The
nurse should:
A. Restrict fluids to 500 mL/day
B. Notify the provider (fluid retention)
C. Encourage a high-sodium diet
D. Document as expected finding
Answer: B
Rationale: Rapid weight gain (>2–3 lb/day) indicates worsening heart failure.
